Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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How many procedures are performed at these locations per year?
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Assessment Group Members
Incident/Mishap History
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Have there every been incidents of electrical shock to staff or patients in these areas?
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Were the incidents investigated by qualified safety personnel (i.e. Patient Safety, Hospital Safety Officer?
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What was the root cause and what corrective actions were implemented to prevent reoccurrence?
Assessment Questionnaire
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Does surgical staff perform procedures that generate standing fluid on the floor?
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Do surgical staff perform procedures that generate drenching of the work area?
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Are extraction systems available to reduce the liquid on the floor?
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Are line power cords on the floor within six (6) feet of the patient or line power suspended from the ceiling that could reach within six feet of the patient?
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Are line cords, attachment plugs, and exposed metal routinely inspected, repaired or taken out-of-service until fixed?
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Is a visual inspection of all equipment completed before starting any surgical procedure?
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Does medical electrical equipment comply with IEC ANSI/AAMI ES60601-1?
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Do you have procedures to manually contain or remove fluids during a procedure (i.e. absorbent pads)?
Hospital Safety Officer
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Comments
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